By Debra Jasper
and Spencer Hunt
The Cincinnati Enquirer
The disabled and poor are having an increasingly tough time finding doctors who will take them. Soon, it could get even tougher.
Doctors say they can't survive on state Medicaid payments that fail to cover basic costs of seeing patients. Ohio hasn't increased payments to doctors in three years. Kentucky hasn't raised rates since 1993.
Unless payments go up soon, doctors in both states say they will cut back on treating Medicaid patients. In Ohio, just 28 percent of doctors surveyed last year by the Ohio Coalition of Primary Care Physicians said they would continue to see Medicaid patients on an unlimited basis if the state refuses to pay them more money.
Doctors warn that the trend is creating a two-class system where the rich and well-insured get better doctors and specialists. Everyone else - the poor and working-class families with severely ill children - will struggle to find a doctor willing to treat them and advocate on their behalf.
"There are definitely haves and have-nots in this system," says Dr. Richard Tuck, a Zanesville pediatrician. "What we have now is a two-class system of care that is unsustainable."
He and other doctors in Ohio and Kentucky say the system isn't just failing families, it's costing taxpayers millions of extra dollars. That's because people on Medicaid who can't find regular doctors often seek help from expensive emergency rooms.
"There's no question that for some patients, emergency rooms have become the main method of care," says Dr. Greg Cooper, president-elect of the Kentucky Medical Association.
He says he has been forced to cut back the number of Medicaid patients he sees in his Cynthiana family practice - from 25 percent four years ago to 15 percent today. "The type of insurance a person has shouldn't be a factor in patient care," he says. "But it's difficult to run a practice if you aren't getting reimbursed."
Tim Maglione, a senior director for the Ohio State Medical Association, says problems are intensified in Ohio where costly regulations are increasing while payments for office visits stay stagnant.
"Doctors who take Medicaid have to spend as much time on paperwork as they do on patient care," he says. "No doctor wants to be in a position where they can't take care of people who need help. But when expenses outpace revenue, a practice can't stay afloat."
William Hayes, an assistant deputy director in the Ohio Department of Job and Family Services, says the state recognizes the problems. But in a tight economy, he says there's no new money in the Medicaid program to pay higher rates for doctor visits - even if it could save tax dollars down the road.
"We're trying to get people hooked up to a primary care physician because that's important. It will keep them out of the emergency room," he says. "So we are taking reimbursement issues seriously. But we face real challenges."
'The real travesty'
While state officials search for a solution, Tuck and 37 other doctors in his medical group have stopped taking new Medicaid patients in Zanesville, near Columbus. Tuck says the doctors had no choice.
"Medicaid is reimbursing us at least 5 percent below our fixed costs for overhead, utilities and nurses' salaries, not counting our own salaries," Tuck says. "A third of our practice used to be Medicaid patients, but now it's down to 10 percent."
He says the situation doesn't make sense because Medicaid will pay less for patients to see a private doctor than it will pay for people to seek help in a nearby clinic - even though a physician is often unavailable there.
Medicaid pays $60 for a 15-minute visit at a clinic run by a children's hospital or teaching hospital. It will only pay $34 for the same visit in a doctor's office. "The real travesty in all of this is that doctors want to see these children, and we could see them for the same money the state is spending on clinic and emergency room care," Tuck says. Tuck's wife, Cynthia, a nurse practitioner at the Zanesville clinic run by Genesis Health Care Systems, says the lack of doctors willing to take Medicaid has created a huge demand for clinic care. Her clinic serves 1,600 people, but a doctor is available only about six hours a week.
"Many of our patients are used to going to the emergency room," she says. "If I'm not comfortable treating them, that's where I send them."
Barb Edwards, Ohio's Medicaid director, says Medicaid pays more for clinics attached to hospitals because they are more costly places. Some, she says, offer patients more attention from doctors - not less. Still, she says she will take a new look at the state's payment plans, noting, "We are open to a new policy in terms of how we buy services."
Edwards adds that officials also will examine whether the state's payment rates have created a shortage of doctors willing to take Medicaid patients. "Do I think parents are having a hard time finding a doctor?" she asks. "They are getting services from somewhere, but whether those are services they like, I don't know."
Edith Andrews spent more than a year trying to find a private doctor willing to take her Medicaid card and treat her severely ill twin daughters, Sarah and Samantha.
Until then, her babies had to go to the Zanesville clinic or an emergency room, where they saw a different doctor every time, if they saw a doctor at all.
"The day I found a doctor to take them, I said, 'Yes, there is a God,' " says Andrews, of Cumberland, Ohio. "My daughters shouldn't have to see doctors they don't know and get tests they don't need. They're more important than a bad medical system."
When the girls were born premature two years ago, each weighed less than 3 pounds and needed a ventilator to breathe. One girl's lungs collapsed.
"Sarah's complications got worse and worse, and there was never a doctor around when I needed to talk to somebody," Andrews, 27, recalls. "I spent a lot of time in the emergency room, because Medicaid would pay and I knew I could see a doctor there."
Last year, Andrews was diagnosed with cancer in her lymph nodes and started chemotherapy. She grew more determined to find a regular doctor for her daughters and finally convinced Tuck, who had been her own pediatrician when she was a child, to take them.
"He was the only one I had luck persuading," she says. "You wouldn't believe how much it's helped."
Tuck decided to treat Andrews' daughters because they were so ill and desperately needed help, but he says he can't afford to keep making exceptions.
"The system is broken," he says. "I really think that if it weren't for doctors who continue to see these (Medicaid patients), it would totally fall apart."
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